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The Impact of a Skilled Nursing Facility on the Cost of Surgical Treatment of Major Head and Neck Tumors
Hadi Seikaly, MD, FRCSC;
Karen H. Calhoun, MD;
Jana S. Stonestreet, RN, MSN;
Christopher H. Rassekh, MD;
Brian P. Driscoll, MD;
Phylis Averyt, CPA
Arch Otolaryngol Head Neck Surg. 2001;127:1086-1088.
ABSTRACT
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Background The finite resources available for health care and the proliferation
of managed care in the United States have forced the head and neck surgeon
to critically evaluate the cost of tumor treatment.
Objective To determine whether the cost of treating patients with head and neck
tumors would be reduced if the patients were to spend a portion of what would
otherwise be acute care hospital days in a hospital-based skilled nursing
facility (HB/SNF).
Design Retrospective cost-benefit analysis.
Setting Tertiary referral center.
Patients Twenty-four consecutive hospital admissions for definitive surgical
treatment of head and neck tumors were retrospectively reviewed. The postoperative
day on which the patient theoretically could have been transferred to the
HB/SNF was determined. The charges and cost of each patient's actual hospital
stay were compared with the theoretical counterparts had the patient been
transferred to the HB/SNF on the determined day.
Main Outcome Measure Cost savings.
Results The total hospital stay for the 24 patients was 524 days. One hundred
eighty-two of those days could have been spent in the HB/SNF. The total charge
and cost savings with the use of an HB/SNF were $201 045 and $84 238,
respectively (15% of the total charge and cost). This represents an average
charge and cost savings of $8377 and $3510, respectively, per patient. The
difference was statistically significant (P<.005).
Conclusion An HB/SNF could reduce the cost of head and neck tumor treatment without
compromising patient care.
INTRODUCTION
THE FINITE resources available for health care and the proliferation
of managed care in the United States have forced the head and neck surgeon
to critically evaluate the cost of tumor treatment. One of the major expenditures
in the management of patients with head and neck tumors is the cost associated
with in-hospital treatment. Some strategies, such as outpatient workup, same-day
admission, clinical pathways, and early discharge from the hospital with skilled
home care support, have greatly reduced the length of hospitalization, but
a certain amount of in-hospital observation is still imperative for proper
recuperation and recovery of the patient after major surgery.
Subacute care is a relatively new strategy that provides required levels
of nursing and medical care for patients at a reduced cost from acute care.
The treatment focus is short-term and on one or more active complex medical
conditions not requiring sophisticated technology or complex diagnostic tests.
Nursing and medical intensity fall in between acute care hospital and traditional
nursing facility (formerly referred to as intermediate care facility or nursing
home) levels. The subacute care category includes nursing facilities, subacute
rehabilitation, and freestanding or hospital-based skilled nursing facilities
(HB/SNFs).
Hospital-based and freestanding SNFs are subject to the same Medicare
requirements of participation, including the same survey, certification, and
enforcement provisions, as acute care hospitals.1
Hospital-based status requires further hospital integration with shared governance
and a common cost report filed annually. Specific facility requirements include
a common dining area to accommodate family style meals and an activity area.
Activities, either group or individualized, to accommodate patient's abilities
are provided for patients at least 5 hours a day, 7 days a week. Hospital-based
SNFs also provide from 3 to 9 registered nurse care hours per day2 and rehabilitative services, such as physical, occupational,
and speech therapy.
There are many advantages to using an HB/SNF for postsurgical subacute
care. The proximity of the facility to the acute care hospital permits the
more medically complex patient to be admitted, allows the surgeon to observe
the patient daily, and facilitates access to emergency care services (resuscitation
team) and to diagnostic services (laboratory and radiology). The transfer
of the patient to the HB/SNF provides the patient and family the security
of familiar surroundings, with some clear differences. The activities, the
common dining room, and the multidisciplinary programmatic focus of maximizing
the patient's independence and overall functioning clearly communicate to
the patient and family that the focus has advanced from acute illness to maximizing
recovery. The design of a clear programmatic focus also minimizes the use
of laboratory, radiology, and other services normally associated with acute
hospitalization, resulting in a more cost-efficient setting for these patients.
The University of Texas Medical Branch (UTMB), Galveston, is an institution
with a demographic profile that lends itself to long hospital stays. Several
factors lead to this problem: (1) Many patients are referred from long distances
(as much as 10 hours by automobile). (2) Many patients have no transportation.
(3) Many patients have limited financial resources for medical care or are
completely uninsured. (4) Many of the counties that the patients come from
have no head and neck cancer care services and do not provide financial aid
to their citizens. The cost of caring for these patients in a subacute setting
is estimated to be as much as 40% to 60% less than comparable care provided
in an acute care facility. We, therefore, hypothesized that the cost of treating
patients with head and neck tumors could be reduced without compromising the
standard of care if the patients were to spend a portion of what would otherwise
be acute care hospital time in an HB/SNF.
PATIENTS AND METHODS
Twenty-four consecutive admissions for surgical treatment of head and
neck tumors at UTMB were retrospectively reviewed and analyzed. Patients undergoing
thyroid and salivary gland resections not requiring neck dissections or major
reconstruction were not included.
The criteria for transfer of the postoperative patients with head and
neck tumors to the HB/SNF were established in conjunction with the nursing
director. The patient must (1) be hemodynamically stable, (2) be afebrile,
(3) require minimal tracheotomy care, (4) have no more than 2 intravenous
medications, (5) require no more than 2 daily dressing changes, and (6) have
a drain output of less than 24 mL/24 h. Minimal tracheotomy
care was defined as care that required the attention of nursing or
respiratory therapy staff no more than twice daily. The dates of potential
transfer of the 24 patients to the HB/SNF were determined. Each patient's
bill was itemized and reviewed by the Department of Healthcare Financial Management
at UTMB to determine the actual hospital charges for the entire stay. A theoretical
charge was then calculated by subtracting from the total charge the charges
covered by the HB/SNF (bed, nursing, physical therapy, speech therapy, radiology,
laboratory, hospital supplies, and pharmacy charges) that were accrued during
the days that the patient could potentially have been transferred to the HB/SNF,
and then adding the HB/SNF per diem charge ($425 at UTMB) for those days.
The actual cost to the hospital was estimated by the Department of Healthcare
Financial Management to be 41.9% of the charges. Finally, the charge and the
cost of the patient's hospital stay was compared with the calculated theoretical
counterparts had the patient been transferred to the HB/SNF on the determined
day. The t test was used to analyze the data, with P<.05 considered statistically significant.
RESULTS
Twenty of the patients were male, and 4 were female. Nineteen patients
had upper aerodigestive tract squamous cell carcinoma, 2 had undifferentiated
maxillary sinus carcinoma, and the remaining 3 had juvenile angiofibroma,
metastatic papillary thyroid carcinoma, and metastatic parotid adenocarcinoma
(1 patient each). Of the 23 patients with malignancy, 18 had stage IV disease,
4 had stage III, and 1 had stage II.
The hospital length of stay, the theoretical HB/SNF length of stay,
the total charges, the charges adjusted for the HB/SNF, and the savings for
each patient are shown in Table 1.
The total hospital stay for the 24 patients was 524 days; 182 of those days
(35% of the total stay) could have theoretically been spent in the HB/SNF.
The total charge and cost savings with the use of the HB/SNF were $201 045
and $84 238, respectively (15% of the total charge and cost). This represents
an average charge and cost saving of $8377 and $3510, respectively, per patient.
The difference is statistically significant (P<.005).
COMMENT
Cost control and the efficient use of available resources are becoming
increasingly important in modern medicine, but it is imperative that none
of these measures adversely affect the quality of patient care. Hospital-based
SNFs are relatively new and offer many advantages. The usual proximity to
the active care units allows the responsible physician to observe the progress
of the patient, with qualified nursing staff and easy access to resuscitation
teams and diagnostic services. The patients are more comfortable with the
familiar surroundings, and they notice a clear shift in emphasis from acute
illness to recovery and rehabilitation. Most HB/SNFs charge per diem rates
($425 at UTMB), which include charges for the bed and nursing, hospital supplies,
pharmacy, and ancillary services (speech pathology, laboratory, and radiology),
therefore reducing the cost to the patient.
The average hospital stay was 21.8 days (range, 7-58 days), which is
a reflection of our patient population. Most patients with head and neck tumors
at UTMB are indigent, and have advanced disease requiring complex surgery.
They are also unable to access outpatient services because of the distance
they would have to travel, their lack of financial resources, and the lack
of outpatient services in their communities. The postoperative teaching and
rehabilitation, which is usually supplied on an outpatient basis, has to be
performed in the hospital, extending their hospital length of stay.
The HB/SNF transfer criteria we established seem to be accurate at determining
the appropriate time for transfer. The total savings in charges and costs
for the 24 patients were $201 045 and $84 238, respectively, per
year (15% of the total charges and costs). These savings are considerable,
especially since there would have been no apparent negative impact on the
quality of care and on patient outcome.
CONCLUSIONS
Use of HB/SNFs could reduce the cost of head and neck tumor treatment
without diminishing the quality of care. An actual study in institutions that
share demographic features with UTMB would confirm the data from this theoretical
study and should be undertaken.
AUTHOR INFORMATION
Accepted for publication March 27, 2001.
Corresponding author: Hadi Seikaly, MD, FRCSC, Division of Otolaryngology–Head
and Neck Surgery, University of Alberta, Office 401, 11044-82 Ave, Edmonton,
Alberta, Canada T6G 0T2 (e-mail: hseikaly{at}powersurfr.com).
From the Division of Otolaryngology–Head and Neck Surgery, University
of Alberta, Edmonton (Dr Seikaly); the Departments of Otolaryngology–Head
and Neck Surgery (Drs Calhoun and Driscoll), Clinical Affairs (Ms Stonestreet),
and Healthcare Financial Management (Ms Averyt), University of Texas Medical
Branch, Galveston; and the Department of Otolaryngology–Head and Neck
Surgery, University of West Virginia, Morgantown (Dr Rassekh).
REFERENCES
1. Micheletti JA, Shlala TJ. Understanding and operationalizing subacute services. Nurs Manage. 1995;26:49, 51-52, 54-56.
2. Griffin KM. Evolution of transitional care settings: past, present, future. AACN Clin Issues. 1998;9:398-408.
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